Presentation on theme: "Focus Charting The Focus Charting System is the accepted documentation system at Windsor Regional Hospital."— Presentation transcript:
1 Focus ChartingThe Focus Charting System is the accepted documentation system at Windsor Regional Hospital.
2 Advantages of Focus Charting Flexible enough to adapt to any clinical practice setting and promotes interdisciplinary documentationCenters on the nursing process, including assessment, planning, implementation and evaluationInformation is easy to find because data is organized by the focus.It promotes communication between all care team members.
3 Advantages of Focus Charting Encourages regular documentation of patient responses to careHelps organize document so that it is concise and preciseCan be easily adapted to computer based documentation systems
4 Focus Charting Combines The Focus: It describes the focus of actionsDAR format: Is the structure used to document patient assessment, care interventions or actions and patient responses to the actions or care
5 The Focus System Uses: Progress Notes Focus Lists Flow Sheets Care PlansFlow Sheets
6 Developing the FocusRefers ToExampleA patient behaviourInability to ambulateAn acute change in the patient’s conditionLoss of consciousness or increase in blood pressureA significant event in the patient’s therapySurgeryA special patient needDischarge planning needHypotension, or chest painA sign or symptomA focus may also be written in the format of a nursing diagnosis
7 Entering the Focus on the Focus List: A FOCUS LIST sheet is used as an index or quick reference for what you will find in the progress notes. All disciplines should record on the focus listEntering the Focus on the Focus List:The focus is numbered in order that they are listedDocument the focusThe date the focus is identified is indicated in the active column12Inability to ambulateChest painNursingNursing, PT11/12/01The dates are entered if the focus is resolved or resinstatedThe discipline entering the focus should identify themselves.
8 The Focus ListAdditional Information about the Focus ListFocus Lists must be regularly updated and expanded as the patient’s condition changesAt discharge, focus list needs to be checked to ensure that all the foci have been addressed and / or resolved.
9 Once a focus has been identified, a plan of care needs The Use of Care PlansOnce a focus has been identified, a plan of care needsto be documented.All disciplines should have a plan of care.“Care Plans” are included either as a standard nursing care plan or as an entry in the progress notes under the “A”.Standardized care plans should be activated with the patient and/or significant other’s input in order to make it individualized.Care plans should be regularly updated as required.
10 Flow SheetsThere are numerous pre-printed flow sheets available at WRHThese are helpful in accurately and concisely documenting routine and frequently collected dataUse flow sheets whenever it is logical and helpful to do so. For example: Any documentation which is required on a regular basis by hospital policy or standard.Any nursing care activity which is provided on a regular basis i.e. activities of daily living
11 Flow Sheets Examples of Flow sheets are: vital signs record, medication record,intake and output,post op flow sheet,wound assessment record
12 Flow SheetsAll flow sheets must be correctly dated and must contain the patient’s name on both sides.All entries on the flow sheets must be initialed (no use of check marks) by the person who assesses or provides the care and must have initials with full signature on a master copy.Any variances from normal should be recorded in DAR format01/12/02JS
13 Flow Sheets Do’s Don’ts Charting on the flow sheets should be done as the care is delivered or patient data observedDevelop assessment parameters that have meaning to everyone for example: Check abd incision q2h for drainage, redness, tenderness versus check incisionMake the flow sheets reflect the care needs of the patientBe conciseAnalysis of the trends in the patient data to assess if there are changes in the patients conditionWrite legiblyDon’t leave blanksDon’t squeeze data into spaces provided. If not adequate space it is necessary to progress noteDouble document in various parts of the charting systemDon’ts
14 Progress Notes Are Used to: Provide detail to data in a flow sheet. Document patient response to care.Record an unusual or unexpected event. record changes in patient condition and notification to the MDDescribe the status of the patient at the time of admission, transfer from one nursing unit to another, or at the time of discharge.
15 Progress NotesWhen writing progress notes you should include information about:The details about the patient’s condition (assessment data)The interventions or nursing actions implemented and their effectivenessThe patient’s response to care
16 How to Complete a Progress Note Notes are chronologically entered. The date and time is documented in the columns provided. The time and date you are actually writing the note is used.Nov. 12/011400O.T.#1 -Swollen painful left handD - Assessment done as per referralLeft hand swollen. Digits in extension.---Painful to passive rangingA - Discussed splint use and benefits with Pt.Splint molded. On-off schedule developed.R - Pt. concerned splint will be painful------The service or discipline writing the note is recordedK. Smith O.T.In focus charting the structure of the progress note that follows the focus uses a DAR outline: Data, Action ResponseWhen starting a note the focus is documented first
17 How to Complete a Progress Note D.A.R.Is an acronymDData - subjective & objective patient assessment data that supports the Focus Statement or describes observations of a significant eventAAction - immediate or future actions or plans of action or care based on the evaluation of assessment dataRResponse - the patient response to the action taken.
18 Progress NotesThe Response may not need to be immediately charted. There may not be an immediate response, therefore, only Data and Action may be charted Eventually, there should be a Response entered to that action takenJoan Smith R.N.Joan Smith R.N.There may be more than one focus that requires charting at one timeProgress notes must have a signature after each entry
19 Progress NotesDateTime22 June 981500Nrsg.#1 pneumoniaD - pt. c/o of chest pain on inspiration, fatigue.T-39.5 at 1515, wheezy breath sounds, productivecough for purulent tenacious sputum. IV infusing.A - 02 at 3 litres, chest x-ray this am, sputumfor C&S referral for chest physio. Tylenol ii forelevated temp at Fluids encouraged.Amy Nurse, RPNWrite patient progress notes only when necessary. The goal is to minimize duplication of information and to save time.
20 Focus Charting Do’s and Don’ts Progress notes can be improved by choosing language which is:ObjectivePreciseSpecificThoroughInconsistencies in documentation can leave you and the health care facility open to accusations of incompetence.A medical record containing inconsistencies can be difficult to defend in court.DO NOT use words like confused, uncooperative and depressed. These words may be interpreted in different ways and are not specific in accurately describing the patient
21 Focus Charting Do’s and Don’ts Poor WordingGood WordingEats poorlyPatient confusedUncooperativePatient complaining of painGood dayDiuresing wellWalking ad libAte 1/2 the meal and drank 80 ml fluidPatient unable to recognize familyRefuses to assist with am careComplaining of constant, sharp RUQabd. PainPatient states has been pain freewithout medication and still able tocomplete activities of daily livingLasix 10 mg IV at 1430 resulted in1000 ml of clear, yellow urine.Walks around the unit, up to the elevatorand back to room without any discomfort
22 Avoid Summarizing or using Value Judgements In SummaryBe FactualBe SpecificBe PreciseBe ThoroughAvoid Summarizing or using Value Judgements